Bill Text: AZ SB1291 | 2025 | Fifty-seventh Legislature 1st Regular | Introduced
Bill Title: Health insurers; provider credentialing; claims
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced) 2025-03-03 - Senate Committee of the Whole action: Do Pass Amended [SB1291 Detail]
Download: Arizona-2025-SB1291-Introduced.html
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REFERENCE TITLE: health insurers; provider; payment; claims |
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State of Arizona Senate Fifty-seventh Legislature First Regular Session 2025
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SB 1291 |
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Introduced by Senator Angius
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AN ACT
amending sections 20-3451, 20-3453 and 20-3456, arizona revised statutes; relating to provider credentialing.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Section 20-3451, Arizona Revised Statutes, is amended to read:
20-3451. Definitions
In this chapter, unless the context otherwise requires:
1. "Applicant" means a provider that submits a credentialing application to a health insurer to become a participating provider in the health insurer's network.
2. "Application" means an applicant's initial application to be credentialed as a participating provider.
3. "Complete credentialing application" means the submission of a health plan's credentialing application, including any supporting documents.
3. 4. "Credentialing" means to collect, verify and assess whether a provider meets relevant licensing, education and training requirements to become or remain a participating provider.
4. 5. "Designee" means a third party to whom the health insurer has delegated credentialing activities or responsibilities.
5. 6. "Health insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or a hospital, medical, dental and optometric service corporation and includes the health insurer's designee. Health insurer does not include a pharmacy benefits manager as defined in section 20-3321.
6. 7. "Loading" means to input a participating provider's information into a health insurer's billing system for the purpose of processing claims and submitting reimbursement for covered services.
7. 8. "Participating provider" means a provider that has been credentialed by a health insurer or its designee to provide health care items or services to subscribers in at least one of the health insurer's provider networks.
8. 9. "Provider" means a physician, hospital or other person that is licensed in this state or that is otherwise authorized to furnish health care services in this state.
9. 10. "Recredentialing" "Recredential" means to confirm that a participating provider is in good standing by a health insurer or its designee and does not require submitting an application or going through a contracting and loading process.
10. 11. "Subscriber" means a person who is eligible to receive health care benefits pursuant to a health insurance policy or coverage issued or provided by a health insurer.
Sec. 2. Section 20-3453, Arizona Revised Statutes, is amended to read:
20-3453. Credentialing; loading; timelines; exception
A. Except as provided in subsection C d of this section, the health insurer shall conclude the process of credentialing and loading the applicant's information into the health insurer's billing system within one hundred forty-five calendar days after the date the health insurer receives a complete credentialing application.
B. A health insurer shall provide written or electronic confirmation:
1. Within two business days on receipt of a complete credentialing application.
2. Within seven business days on receipt of a credentialing application with deficiencies.
B. c. A health insurer shall provide written or electronic notice of the approval or denial of a credentialing application to an applicant within seven calendar days after the conclusion of the credentialing process.
C. D. If a licensed health care facility has a delegated credentialing agreement with a health insurer, the health insurer is not responsible for compliance with the timeline prescribed in subsection A of this section for an applicant who works for that facility, but shall conclude the loading process for that applicant within ten calendar days after the health insurer receives a roster of demographic changes related to newly credentialed, terminated or suspended participating providers.
Sec. 3. Section 20-3456, Arizona Revised Statutes, is amended to read:
20-3456. Covered services; claims
A health insurer may not deny shall pay a claim for a covered service provided to a subscriber by a participating provider who has a fully executed contract with a network plan if the covered services are provided after the date of approval of the credentialing application participating provider's credentialing application has been approved retroactively by the health insurer to the date of the participating provider's complete credentialing application.
